NUTRITION COUNSELING
CLIENT INFORMATION
WELCOME TO CLEVELAND STATE UNIVERSITY’S CAMPUS RECREATION CENTER!
Please review
the Member policies
and Procedures Manual
for all inquiries
concerning the Nutrition
Counseling program.
Thank
you for your
interest in our
Nutrition Counseling program. We
want to help you reach your health and
fitness goals by pairing you up with our
Registered Dietitian. Before you begin
your program, please take a moment to
fill out the following information.
This packet
includes the
following:
- Nutrition
Counseling
Prices and
Information
- Nutrition Client
Questionnaire
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All information submitted in this packet will be
kept confidential. Client information
regarding health history in any form
may only be accessed by appropriate
staff of Cleveland State University
Campus Recreation. Appropriate
staff may include, but is not
limited to, the Registered
Dietitian, Fitness & Wellness
Coordinator and Associate
Director of Programs.
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216.802.3256
NUTRITION CLIENT QUESTIONNAIRE
Date:
First Name:
Last Name:
Occupation:
Student:
Gender: Female Male
Age:
Height:
ft.
in.
Member at CSU Recreation Center:
Yes
No
(Circle One)
Weight:
Yes
No
(Circle One)
*Please list three days and time frames that you would be available for a nutrition
consultation:
1.
2.
3.
Day:
Day:
Day:
Time:
Time:
Time:
**Please be aware that while we will make every effort to accommodate the provided
times, we cannot guarantee that a dietician will be available to meet your exact
schedule. Thank you in advance for your understanding.
Medical Conditions/Concerns:
Current exercise regimen (Describe):
Nutrition goals:
Has your physician recommended that you follow any type of diet?
Is your physician aware of your nutritional goals? Does he/she agree with these
goals?
Would you like information on starting an exercise program? Yes
No
Additional Comments/Information for the Dietitian:
INFORMED CONSENT
I understand that nutrition counseling provided is not medical treatment or
substitute for any treatment. I have provided truthful personal medical data and
am seeking nutritional counseling with the approval of my physician. I
understand nutrition counseling is voluntary and that I may discontinue
participation at any time without penalty or prejudice toward me.
By signing my name below, I further certify that I have read and understood the
terms and conditions of this agreement and intend to legally be bound by it.
Signature:
Date: